Elsevier

Clinical Lung Cancer

Volume 17, Issue 5, September 2016, Pages 419-426
Clinical Lung Cancer

Original Study
Impact of Age on Long-Term Outcomes of Surgery for Malignant Pleural Mesothelioma

https://doi.org/10.1016/j.cllc.2016.03.002Get rights and content

Abstract

Background

Although malignant pleural mesothelioma (MPM) is generally a disease associated with more advanced age, the association of age, treatment, and outcomes has not been well-characterized. We evaluated the impact of age on outcomes in patients with MPM to provide data for use in the treatment selection process for elderly patients with potentially resectable disease.

Patients and Methods

Overall survival (OS) of patients younger than 70 and 70 years or older with Stage I to III MPM who underwent cancer-directed surgery or nonoperative management in the Surveillance, Epidemiology, and End Results database (2004-2010) was evaluated using multivariable Cox proportional hazard models and propensity score-matched analysis.

Results

Cancer-directed surgery was used in 284 of 879 (32%) patients who met inclusion criteria, and was associated with improved OS in multivariable analysis (hazard ratio, 0.71; P = .001). Cancer-directed surgery was used much less commonly in patients 70 years and older compared with patients younger than 70 years (22% [109/497] vs. 46% [175/382]; P < .001), but patients 70 years and older had improved 1-year (59.4% vs. 37.9%) and 3-year (15.4% vs. 8.0%) OS compared with nonoperative management. The benefit of surgery in patients 70 years and older was observed even after propensity score-matched analysis was used to control for selection bias.

Conclusion

Surgical treatment is associated with improved survival compared with nonoperative management for both patients younger than 70 years and patients aged 70 years or older.

Introduction

Malignant pleural mesothelioma (MPM) is a highly aggressive cancer with a relatively poor prognosis and a median survival of approximately 12 months.1, 2, 3 Owing to a long latent stage, 58% of patients diagnosed with MPM are over the age of 70 years upon presentation,4 and the incidence of elderly patients diagnosed with MPM globally is increasing.5, 6, 7, 8, 9, 10 Although increasing age has consistently been shown to be associated with worse survival,3 there are very few studies that report specific outcomes among elderly patients. In particular, the survival benefit of surgery for elderly patients with MPM has not been clearly established.3, 11 Quantitative data to support difficult treatment decisions about when to offer surgery for elderly MPM patients are needed, as a subset of these patients with favorable prognostic factors may experience extended survival by undergoing cancer-directed surgery. In the present study, we analyzed the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2010 to evaluate the survival of elderly patients with MPM and to determine how age impacts the potential benefits of surgery for patients with MPM. Our objective is to provide clinicians with quantifiable evidence that can be used in the treatment decision process for elderly patients with MPM and to specifically test the hypothesis that surgery is associated with survival benefit in elderly patients.

Section snippets

Materials and Methods

This study of the SEER program database was approved by the Institutional Review Board at Duke University. Patients included in this study were those 18 years or older with epithelioid and biphasic MPM diagnosed between 2004 and 2010. Only cases identified from 2004 to 2010 were evaluated because specific American Joint Committee on Cancer's TMN staging (Sixth Edition)12 information was available in SEER only from 2004 to 2010, as staging was categorized as “early” and “late” in earlier SEER

Baseline Characteristics

A total of 879 patients with stage I to III MPM of nonsarcomatoid histology from 2004 through 2010 were identified for inclusion in this study. Cancer-directed surgery was used in 32% (n = 284) of these patients. Baseline demographic, treatment, and tumor characteristics of patients who were managed nonoperatively and patients who underwent surgery are detailed in Table 1. Patients treated with surgery were younger, had higher stage disease, slightly higher frequency of biphasic disease, and

Discussion

In this population-based study, we found that age was an important determinant both for survival and for the use of cancer-directed surgery. Patients age 70 and older were much less likely to have surgery compared with younger patients. Patients 70 years and older who underwent cancer-directed surgery had a worse survival compared with patients younger than 70 years, but surgery was associated with higher survival when compared with nonoperative management in both patient age groups. However,

Conclusions

In summary, surgical treatment of mesothelioma is associated with improved long-term outcomes, even among the elderly, in a national population-based cancer database. Although this database has inherent limitations, the analysis does suggest that appropriately selected elderly patients potentially derive benefit from surgery. While these results cannot be used to show a definitive benefit to surgery in all elderly patients, the analysis does suggest that advanced age alone should not be used as

Disclosure

The authors have stated that they have no conflicts of interest.

Acknowledgments

Dr Yang is supported by the American College of Surgeons Resident Research Scholarship. Mr Meyerhoff is supported by a MSTP T32 grant (Medical Scientist Training Program NSRA T32GM007171). Drs Gulack and Hartwig are supported by the NIH funded Cardiothoracic Surgery Trials Network grant #: 5U01HL088953-05.

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